A Caffeinated Classification Criticism – Part 1

Dr. Y: I read your Imelda blogs. Entertaining, but they miss the point.

Me: What point?

Dr. Y: Here in the U.S. we use codes for payment.

Me: I know. I couldn’t think of a way to work that in without making the analogy too complicated.

Dr. Y: It’s key. For thirty years, since ICD-9, we physicians have been battling the insurance companies about how to get paid and only in the last few years have things settled down a bit. Now you want to start the battle all over again.

Me: We’re not proposing to change the payment rules, not yet anyway. Coders will just …

Dr. Y: Coders are not the issue. Let me explain. The process is different for small organizations without coders than it is for larger ones, like hospitals, which have them. But the effect on us doctors is the same. Have you ever tried to understand the clinical definitions behind the systems we face? PQRS, NCDs, RBRVS, IOCE, DRGs, – the whole alphabet soup?

I knew what he was talking about. I’d been involved in converting some of these to ICD-10. I nodded.

Dr. Y: And did they make complete sense? Could you explain, for example, why there are tons of vascular procedures listed for the gastrointestinal DRGs?

Me: Not off the top of my head, no.

Dr. Y: And you’ve been doing this…?

Me: Forty-five years.

Dr. Y: So imagine what it is like for me, with patients to treat and a practice to run. I have to resort to trial and error, or hire expensive consultants, or both, to get paid enough to keep going. In our practice, which is too small for professional coders, we’ve discovered over the years what works and what doesn’t and have had it printed up in an ICD-9 checklist …

Me: The super-bill, yep. Those shouldn’t be all that expensive to translate.

Dr. Y: (ignoring my interruption) … and in the hospital, which does have coders and 3M software, you still have the tussle with the payers, but now it is called “documentation improvement.” The coders won’t do it for you – they have their rules and guidelines and professionalism – you can’t just say to them “put down whatever will get us paid what we think we earned.” We have to write it in the chart so they can – hopefully – code it and get us the best deal.

Me: You’re talking about optimizing payment? Gaming the system?

Dr. Y: No, I’m talking about surviving financially in a murky world of rules and regulations as best as I can. In your Imelda blog you said that every code is a simplification – it ignores details to stick the patient in a cubbyhole. If I have to choose between a $500 code and a $1000 code, neither of which precisely describes what I did – why shouldn’t I choose the $1000 one?

Me: A lot of that “murk” you complain about is because ICD-9 is old and insufficiently detailed. With ICD-10, we should be able to get more clarity …

Dr. Y:We? Do you honestly believe there will be no short-term impact from the switch to ICD-10? And even if I can get my super-bill translated accurately, as you suggest, can you assert with confidence that the bureaucrats at the insurance company will translate their payment rules in exactly the same way?

Me: …

Dr. Y: So the bottom line is that ICD-10 is throwing me back to the front lines, restarting the battle with the payers. No wonder we doctors are trying to stop it.

Me: Look, you and I both know that if this country is going to get its health costs under control – more in line with those of other rich countries – we’re going to have to measure, analyze, set non-perverse incentives, design fair payment systems that give you more control – and ICD-9 just doesn’t cut it anymore. We can’t go back to fee-for-service. What would you suggest as the way forward?

Dr. Y: (looking at his watch) Nowadays, they make me enter everything I do into the computer – into EHRs – and they tell me those are based on SNOMED. Why can’t you just use that information – the SNOMED stuff – and stop making me responsible for putting it all in again just to get paid?

I noticed his 20 oz. four-shot no-foam latte was long gone.

Me: I have an answer for that, which ought to convince you that ICD-10 is in your best interest, but it will not be short.

Dr. Y: I usually stop here every Friday morning before rounds.

Me: See you next week.

Ron Mills is a Software Architect for the Clinical & Economic Research department of 3M Health Information Systems.

3 responses to “A Caffeinated Classification Criticism – Part 1”

I really enjoy your articles. It’s nice to go back to basics every so often… He is right that it does take them back to battle, to a degree; however, we (he) also need to recognize that to accomplish the goal of decreasing the cost of health care, we will need to join forces. This brings about the era of accountable care organizations and partnering with one another to practice a more complete care model, where we all share in a portion of a patient’s care. The goal would be to keep people healthy, rather than only treating the sick.

How many of these physicians are actually out there? Ones in small organizations with no coders in their organization? (what’s the percentage of them to all physicians in practices? I’m betting its a small number) So his argument is that we as a country can’t move forward with a classification system that changed over a decade ago because a few physicians can’t adapt? Is this why the AMA is fighting so hard against this change? Discussing DRG changes is also an odd arguement, as DRG changes will not have an impact on his private practice. And if he’s been coding off a superbill, his coding hasn’t been accurate in years anyway. There are tools available to help him with ICD-10 coding. I’ve tested one from Mediregs-actually watched a doc that does not code his own charts in today’s world come up with accurate ICD-10 codes for patients in his practice using their app and it was less time consuming then using the current tool they have embedded in their EMR. There are real world solutions out there, and as a physician he should be adept at adapting to change, particularly in the healthcare environment. He can meet me for coffee next Friday morning-I’d be happy to discuss the benefits of ICD-10 and why change in this case is not only good, its long overdue.

One of the great things about the weblog format is that commenters can say things more forcefully than I would be able to. With respect to the “private practice” issue — Dr. Y feels that within the institutions he’s embedded in, “documentation improvement” still puts him on the front lines, so indirectly he is at the mercy of DRG and other payment system changes — while still adapting to the development of EHRs.